The Beast on My Back

Gerald Weissmann

‘Bête Noire’ is set in Piccadilly during the long winter between the Battle of Alamein and the Normandy invasion. At the time, the 24-year-old Douglas had pretty much recovered from wounds inflicted by German 88s in the Western Desert and by spring he was back in action. On 9 June, three days after landing in France, he was killed behind enemy lines. We can trace the beast to a passage in From Alamein to Zem Zem, in which he describes his escape from a blasted tank over a minefield of wrecked armour and oil-stained corpses:

Presently I saw two men crawling on the ground … I recognised one as Robin. His left foot was smashed to pulp, mingled with the remainder of a boot. But as I spoke to Robin saying, ‘Have you got a tourniquet, Robin?’ and he answered apologetically, ‘I’m afraid I haven’t, Peter,’ I looked at the second man. Only his clothes distinguished him as a human being, and they were badly charred. His face was gone: in place of it was a huge yellow vegetable. The eyes blinked in it, eyes without lashes, and a grotesque huge mouth dribbled and moaned like a child exhausted with crying.

For most combatants, the numbing effects of such battlefield nightmares are relatively short-lived; for some they last a lifetime. The more permanently affected were said in the past to have been ‘touched with fire’ (the American Civil War), suffering from ‘shell-shock’ (World War One) or afflicted by ‘traumatic neurosis’ (World War Two). In each instance the symptoms that patients displayed seemed to split along class lines. ‘Officers complain of nightmares and bellyaches, enlisted men think they’ve been paralysed,’ our psychiatry instructors told us at Fort Sam Houston after the Korean War.

The syndrome was codified after Vietnam. The beast on the back – and a grab-bag of other distressing symptoms – came to be called Post-Traumatic Stress Disorder or PTSD. According to the American Psychiatric Association, the official definition of this condition requires a traumatic event ‘outside the range of usual human experience … one that would be markedly distressing to almost anyone’, followed by such symptoms as repetitive recall of the trauma, psychological numbing, amnesia, insomnia or other forms of automatic arousal. Readers of Robert Graves, Siegfried Sassoon or Pat Barker should not be surprised that this description of PTSD turns out to have a strong resemblance to the description of shell-shock that has become part of the modern literary tradition: the psychiatrists are, after all, simply describing the same beast on different backs.

It might be argued that the beast has been there since records were kept; nightmares have been with us always. Among physicians, Hippocrates had the first look: ‘but the worst of all is to get no sleep either night or day; for it follows from this symptom that the insomnolency is connected with sorrow and pain.’ Two better-known passages suggest something resembling PTSD: Hotspur, with beads of sweat on his brow, rolls in sleep restlessly to mutter ‘Of prisoners ransomed and of soldiers slain/And all the currents of a heady fight’. Guilt after mischief leads the Macbeths to

eat our meal in fear and sleepIn the affliction of these terrible dreamsThat shake us nightly: better be with the deadWhom we, to gain our peace, have sent to peace.

Kipling joined military to civilian motifs and added the element of class in ‘Gentlemen Rankers’:

The full text of this book review is only available to subscribers of the London Review of Books.

Letters

I fail to see the point of Gerald Weissman’s article about Post-Traumatic Stress Disorder (LRB, 6 June). Is he trying to say that it is a great advance to exchange one label for another (’the field changed radically when the nomenclature was revised’)? What used to be called Traumatic War Neurosis, or something similar, is now labeled PTSD – what’s the big deal?

As clinicians know, the DSM (Diagnostic and Statistical Manual of Mental Disorders) is a loose hodge-podge of fuzzy theories, speculations etc, paying lip service to the needs of the times. It is hardly a profound scientific document. Yet his review exclaims: ‘the publication of DSM-IV is a signifying moment.’ This must be the overstatement of the year; DSM is at best a useful rough tool for insurance forms and hospital administrators who must fit patients into neat rubrics. Weissman’s high praise for the so-called experts, ‘pioneers of psychiatric nosology’, is high nonsense. When I was a student, the DSM listed homosexuality as a disorder. These rather desultory listings are decided not on the basis of scientific research, but as a result of personal interest, the Zeitgeist, backroom lobbying, trends etc. How about Multiple Personality? Is that in this year? Or just re-labelled Dissociation?

‘What used to be called Traumatic War Neurosis, or something similar, is now labelled PTSD – what’s the big deal?’ This is what Sheldon Litt wants to know (Letters, 18 July) after reading Gerald Weissmann’s review of my book, The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. The answer depends on the meaning that Litt wishes to give to his first ‘what’. If, as it seems, he is writing about a phenomenon that supposedly transcends the nomenclatures and practices of psychiatry, then one would have to agree that that there is nothing really new about PTSD. But as Weissmann makes clear, it is precisely this idea, that traumatic memory is a timeless essence, that the book rejects. The phenomenon that psychiatry knows as ‘traumatic memory’ is a relatively recent development, and during the century and a half of its existence the character of its symptoms and the identity of its victims have been periodically reconceived. PTSD is the most recent chapter in the history of traumatic memory. Litt is correct when he writes that PTSD shares features with the traumatic neuroses of the First World War, but he is mistaken if he supposes that there are no important differences between these disorders, and that they merely rename a constant underlying reality. The character of the traumatic hysterias and neurasthenias was shaped by the moral sensibilities, political institutions and clinical practices of the 1914-18 period; the character of PTSD has been likewise stamped by American participation in the Vietnam War, by the domestic liberation politics of the Sixties and Seventies, and by the profound technological and social changes taking place in American psychiatry during the same period.

Litt also attacks Weissmann for comments he is alleged to have made concerning the disease taxonomy that has dominated American psychiatry since the Eighties, the so-called DSM system. His argument that the DSM system is not scientific is justified only if one thinks of ‘science’ as a technology for uncovering pre-existing truths rather than as one or more distinctive systems for producing and vindicating knowledge. If science is what scientists do, then the DSM system can be said to have revolutionised the practice of psychiatric science it the United States.

Allan Young
McGill University, Montreal

Sheldon Litt’s letter commenting on the DSM reminded me of this bit of wisdom from DSM-III-R: ‘Beliefs or experiences of members of religious or other cultural groups may be difficult to distinguish from delusions or hallucinations. When such experiences are shared and accepted by a cultural group, they should not be considered evidence of psychosis.’ In short, if we’re all crazy, then we’re not crazy.

Sheldon Litt (Letters, 18 July) has written a shrill response to my review of Allan Young’s book The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. This book, like my review of it, tries to explain not only the fact that doctors invent new names for old syndromes but why they do so. Young’s book describes in some detail and with a good deal of care why, as Litt puts it in his trottoir style, ‘what used to be called Traumatic War Neurosis, or something similar, is now labelled PTSD – what’s the big deal?’ Litt attributes to my review, rather than to its source, Young’s book, unqualified praise for the well-meaning attempts of psychiatrists periodically to revise the terms they use to describe mental disease. Quite often they have gone astray, but so have those of us in clinical investigation who have recently changed our minds about peptic ulcers, rheumatoid arthritis or how aspirin works. Only magical practices like homeopathy, chiropractic or ayurvedic medicine hold steadfast to their nomenclature over the centuries. Litt’s perhaps deliberate misreading of my review, and his failure to consult its source, remind me of the principle announced by Oliver Wendell Holmes in The Autocrat at the Breakfast Table (1858), which he called the hydrostatic paradox of controversy: ‘If you had a bent tube, one arm of which was the size of a pipe-stem and the other big enough to hold the ocean, water would stand the same height in one as in the other. Thus discussion equalises fools and wise men in the same way, and the fools know it.’